In their Making Sense of Integrated Care article published in 2018 the Kings Fund summarised ICPs as follows;‘Integrated care partnerships (ICPs) are alliances of NHS providers that work together to deliver care by agreeing to collaborate rather than compete. These providers include hospitals, community services, mental health services and GPs. Social care and independent and third sector providers may also be involved.’
In Derbyshire we have developed a full cross system collaborative approach and ICP partners comprise acute trusts, community and mental health providers, local authorities (including social care and housing), education, primary care/PCNs and the independent and voluntary sectors.
Our health and care system has worked together since September 2019 and made some real progress including an agreement on the four ICP areas:
i) Chesterfield, North East Derbyshire and Bolsover
ii) Derby City
iii) South Derbyshire, Amber Valley and Erewash
iv) Derbyshire Dales and High Peak
These areas are recognised by our local authorities and this helps to enable a focus on population health, prevention and ensure relevance to local populations. It is recognised that ICPs have a vital role to play although they should not be viewed as the panacea for our Derbyshire system.
The role of the Derbyshire ICPs has been agreed at headline level that they should customise and implement care pathways and support implementation of transformation programmes, build and maintain the ‘supply chain’ of providers and actively support PCNs. Key objectives include being inclusive and also lean through using existing resources innovatively with financial accountability representing around 25% of their overall roles.
At a more detailed level the ICP role needs to understand the local population health, wellbeing and social care needs and prioritise resources so that they can:
• Develop an approach that recognises the wider determinants of health as a key driver of health and wellbeing in the population
• Prioritise prevention across a person’s life to encompass primary, secondary and tertiary health and care provision
• Customise and implement wellbeing and care pathways
• Lead local transformation and integration of agreed priorities
• Ensure focus on transformation of wellbeing and care models rather than clinical pathways and that ensure that these are both localised through Place and PCNs
• Manage resource/spend within agreed budgets (a challenge in year one)
• Reduce waste and duplication including estates and central functions
• Build workforce resilience, roles and recruitment and organisational development
• Integrate information and case management systems to give a holistic view of the person
An immediate priority is to build upon the work delivered so far by identifying leaders for each of the four ICPs including an independent chair for each, using the leadership model below. A process which is fair and transparent is in development and it is clear that these will not be new roles.
Financial performance up to month 9 (end December 2019):
At the end of month 9 the Derbyshire system is reporting being off plan and there continue to be a number of key risks associated with the year-end financial position. Key factors in this include the challenges for both acute trusts and specifically these are tariff change issues for Chesterfield Royal Hospital (CRH) and difficulty in delivering savings associated with the Service Benefit Reviews for University Hospital Derby and Burton UHDB).
Savings plan performance:
The single savings plan for the whole Derbyshire system which incorporates the CCG overall financial performance continues to be reviewed and monitored by the Systems Savings Group. This offers significantly more visibility of the overall financial performance and savings requirements of the system. The 19/20 system financial challenge is now valued at £151m and the planned level of savings at the end of month 9 is £78.4m, although the actual recorded level of savings at the end of month 9 is £70.8m so there is a material shortfall in the recurrent savings forecast.
Managing the end of year position:
A comprehensive recovery plan for the system is in place and this is being worked on intensively by colleagues across the Derbyshire system. Given the variances between the year to date performance and the year-end planned position it will not be possible for either CRH or UHDB to deliver within the Control Totals set by NHS Improvement. The Directors of Finance across the system have collectively agreed that each organisation will contribute to the recovery plan to ensure the delivery of the best system financial position that is possible.
Working towards 2020/21:
The projected financial position for 2019/20 will impact upon 2020/21 in terms of a bigger financial performance and savings challenge. This makes it even more important that there is a dual focus in terms of managing the current year position to achieve the best outcome possible whilst planning ahead for the transformation of the way services are delivered next year to ensure that our shared financial targets are met.
Between November 2019 and January 2020 the Independent Chair and STP Director met with each of the JUCD STP work-streams SRO and Leads with supporting colleagues. The purpose of the meetings was to provide an opportunity for the new Independent Chair to meet with key programme leaders and to understand better the transformational work, identified in the JUCD STP Strategic Plan and the individual work-stream delivery plans, underway on behalf of the system.
The key themes emerging from the discussions noted were as follows:
· The need to focus on a smaller number of major transformation areas with significant resource directed towards these, with other work streams becoming business as usual. This was agreed as a principle by the Board.
· The need to optimise work-stream interdependencies.
· Opportunities to refine governance and progress reporting. Major transformation programmes will report to the Board quarterly and the business as usual work streams report six monthly, although escalation to the Board by exception will be encouraged outside of the agreed reporting framework where intractable issues required a system response or resolution. This will result in the Transformation Assurance Group being stood down which not only streamlines governance arrangements and reduces demand on peoples time, but will further reduce the division between transformation oversight and system savings oversight.
Strengthening Clinical and Professional Leadership in JUCD
Clinical and professional leadership for the Derbyshire system has to date come from the Joined Up Care Derbyshire Clinical & Professional Reference Group (CPRG) which was established in 2016/17 shortly after the publication of the original STP Plan.
A review of the terms of reference of CPRG has been undertaken aimed at strengthening the overarching clinical and professional leadership approach. This has resulted in a review of the leadership arrangements and future positioning of CPRG as we move towards becoming an ICS, to move CPRG into a stronger position to act as the clinical and professional voice for the system. In doing so, this will also put CPRG in a more prominent position within the STP governance arrangements.